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1
Introduction
Temporary anchorage devices (TADs) have become a
common treatment modality in orthodontics within the last
two decades. Still, today the alveolar process is the most
preferred insertion site1~5). However, orthodontists are still
confronted with an average loss rate of 16.1%, as reported in
recent literature6~9). Choosing the anterior palate as insertion
site loss rates could be decreased to values as low as 2.1%10).
Distally from the rugae, an area with sufficient bone volume
and a thin soft-tissue layer can be detected (Figure 1,
T-zone)11). A new generation of mini-implants with
interchangeable abutments (Benefit system, PSM, Germany12))
was developed that allow integration into the orthodontic
mechanics (Figure 2). For high demands on the anchorage
quality, two mini-implants are used and coupled with a
miniplate (Beneplate13), 1.1 mm or 0.8 mm, Figure 2H). These
miniplates can be adapted to the mini-implants by bending of
the miniplate body as well as the wire (Figure 3).
Implant Placement and Adaption of the Mechanics
If the patient is apprehensive about use of a needle syringe,
the miniscrews can be placed using only topical anaesthetic
(jelly). In adult patients, a pilot drilling (2-3 mm depth) should
be performed due to very high bone densities nearby the
suture. In children and adolescents with relatively low bone
mineralization, pilot drilling is not needed. Mini-implants with
diameter of 2 mm or 2.3 mm and lengths of 9 mm (anterior)
and 7 mm (posterior) are inserted, which provides a high
stability (Figures 4-6)14~17).
In many cases the appliance could be adapted intraorally,
which, of course, implies some chair time (Figure 7 A, B).
The alternative is to adapt the mechanics in the laboratory by
taking a silicon impression and transferring the intraoral setup
to a plaster cast using the impression cap and the laboratory
analogue12) (Figure 2 B, C).
Clinical Applications
1. Maxillary Molar Distalization (Beneslider and Pendulum B)
Due to esthetic drawbacks and the length of time to be
worn, molar distalization with a headgear is unpleasant for
many patients18,19). Unfortunately, most of the conventional
devices for non-compliance maxillary molar distalization
show some unwanted side effects, such as anchorage loss,
especially, when distalization forces are applied buccally20).
The amount of the anchorage loss of conventional intraoral
devices ranges between 24 to 55%21). To benefit from the
advantages of direct anchorage mechanics and of the anterior
近東矯歯誌 52:1~7(2017)
Palatal TADs with Exchangeable Abutments in Orthopaedic and Orthodontic Treatment Work
特別講演
Benedict WILMES
University of Duesseldorf, Germany
Figure 1 Picture of a maxilla of a cadaver Recommended insertion site (T-Zone) posterior from
the rugae. The bone is very thin in the posterior and lateral areas.
2 近東矯歯誌 第 52巻 第 1号 2017 年(平成 29年)
palate as the most suitable mini-implant insertion site, the
Beneslider5,12,13,22,23) device has been designed fixed on top of
mini-implants with exchangeable abutments. The Beneslider
utilizes sliding mechanics and has proved to be a reliable
distalization device23) (Figure 8). However, if frictionless
mechanics is preferred and/or the molars are to be uprighted
or derotated simultaneously during distalization, Pendulum
mechanics can be employed24). Several authors introduced
skeletally-supported Pendulum mechanics to avoid anchorage
loss25~28). However, all described appliances require additional
laboratory work. The Pendulum B29) was designed to have the
ability to adapt a skeletal borne Pendulum device chair side
immediately after mini-implants insertion without a laboratory
procedure (Figure 9).
Figure 6 Angulation of the insertion is perpendicular to the bone: The soft tissue anterior is too thick.
Figure 2 Benefit/Beneplate system A. Mini-implant. B. Laboratory analogue. C.
Impression cap. D. Slot abutment. E. Standard abutment. F. Bracket abutment. G. Abutment with wire in place (0.8 or 1.1 mm). H. Beneplate with wire in place (0.8 or 1.1 mm). I. Fixation screw for Beneplate. J. Screwdriver for fixation of abutment or Beneplate on top of the mini-implant.
Figure 3 Bending of the Beneplate to fit on the mini-implants
Figure 4 Manual insertion using a handpiece
Figure 5 Insertion of two mini-implants posterior from the rugae, the distance between the mini-implants should be 8-14 mm.
3Wilmes:Palatal TADs with Exchangeable Abutments in Orthopaedic and Orthodontic Treatment Work
2. Maxillary Space Closure (Mesialslider)The two major treatment approaches are space closure or
space opening to allow prosthodontic replacements either with
a fixed prosthesis or single-tooth implant. In many cases,
space closure to the mesial seems to be the favourable
treatment goal, since treatment already can be completed as
soon as the dentition is complete30). As an alternative to the
T-Bow (indirect anchorage) the Mesialslider12,13,31) as a direct
anchorage device can be used. The Mesialslider enables
clinicians to mesialize upper molars unilaterally or bilaterally.
Since the incisors are not fixed, a midline deviation can be
corrected at the same time. The Mesialslider can be used to
close space in the upper arch from distal, e.g. for missing
lateral incisors (Figure 10), canines (Figure 11), premolars
(Figure 12) or molars. The Mesialslider can also be used for
protrusion of the whole upper dentition to compensate a mild
Class III occlusion.
3. Asymmetric molar distalization and space closure (Mesial-Distalslider)
In many cases with unilaterally missing teeth the midline is
off. The favoured appliance to correct the midline, to close the
space on one side and to distalize the contra lateral segment is
a combination of the Mesialslider and a Beneslider, the
Mesial-Distal-Slider32) (Figure 13).
4. Rapid palatal expansion (RPE) and early ClassⅢtreatment
For the treatment of patients with a Class III caused by a
retrognathic maxilla, RPE is combined with a facemask for
protraction of the maxilla. Since the forces are transmitted to
the dentition, side-effects such as buccal tipping of the anchor
teeth, fenestration of the buccal bone, root resorptions, and
gingiva recessions were reported in some cases33,34). To avoid
these complications caused by the tooth-borne character of the
conventional appliances, some authors reported about pure
Figure 7 Intraoral adaption of a Benetube for a Beneslider (A) Intraoral adaption of the Beneplate for the Mesialslider (B)
A B
Figure 8 Clinical example Beneslider for upper molar distalization.
Figure 9 Clinical example Pendulum B for upper molar distalization.
4 近東矯歯誌 第 52巻 第 1号 2017 年(平成 29年)
bone-borne RPE devices. Several palatal distractors have been
presented over the last decade35,36). However, insertion and
removal of these miniplate-borne distractors are invasive
surgical procedures with the need of a flap preparation, risk of
root lesions and infections35,37). As a consequence distractors
of this type could not establish themselves as standard devices
for RPE. Due to the risk of a root lesion at insertion of
implants in the lateral posterior alveolar process and lack of
available bone in the posterior palate, we used the 1st molars
as posterior anchorage unit. In the anterior median palate there
is more bone available bone for mini-implants38) and the
resulting appliance is a half tooth-borne half bone-borne RPE-
devise called Hybrid Hyrax5,12,39~41) (Figure 14).
The application of the Hybrid Hyrax is minimally surgical
invasive35,36). To employ the 1st molars or 2nd deciduous
molars as posterior anchorage unit and mini-implants as
ske le ta l an te r ior anchorage uni t p rovides severa l
advantages39~41):
Figure 14 Hybrid Hyrax Anterior anchorage is provided by two 2 mm×9 mm
Benefit mini-implants, placed about 5 mm apart. Before and after rapid maxillary expansion and Class III treatment using a facemask.
Figure 10 Clinical example with missing upper right lateral incisor
Mesialslider for unilateral upper mesialization.
Figure 11 Clinical example with missing upper right canine
Mesialslider for unilateral upper mesialization.
Figure 12 Clinical example with missing upper second bicuspids
Mesialslider for bilateral upper mesialization.
Figure 13 Clinical example with missing upper right canine and midline shift
Mesial-Distalslider for unilateral upper mesialization and contralateral distalization.
5Wilmes:Palatal TADs with Exchangeable Abutments in Orthopaedic and Orthodontic Treatment Work
- Applicable in cases with low anterior dental anchorage
quality due to missing deciduous molars or deciduous
molar was short roots.
- Applicable in cases with immature root development of
the premolars.
- No risk of impairment of root development (curved roots).
- Reduction of the dental side effects, i.e. premolar
tipping40).
- Anterior dentition is not bonded during the retention phase
and thus regular orthodontic treatment could be started
earlier.
- Advantageous in cases with need for early Class III
treatment, where the RPE supports maxillary advancement
by weakening the midface sutures.
- Avoidance of mesial migration of the upper dentition
during application of a facemask or the Mentoplate39), thus
enhancing the skeletal effects40).
Treatment of growing Class III patients with maxillary
deficiency is mostly conducted with a facemask. Since the
force is applied to the teeth, mesial migration of the dentition
is inevitable and may result in severe anterior crowding42). On
the other hand, the desired skeletal effect of this commonly
used approach often turns out to be less than expected42). To
overcome these drawbacks and to minimize mesial migration
of the molars, sagittal skeletal support by the Hybrid Hyrax is
very useful. Secondly, to facilitate the advancement of the
maxilla, opening of the midface sutures by rapid palatal
expansion (RPE) is recommended43). With the goal to avoid an
extraoral device (facemask) and to apply the forces directly to
the skeletal structures, De Clerck introduced the use of four
miniplates (two anterior in the lower jaw and two posterior in
the upper jaw) in combination with Class III elastics44). This
represents a new purely skeletal approach to correct the
skeletal discrepancy. In order to enhance the skeletal effect by
opening the midface sutures, we employ the Hybrid Hyrax
appliance in the upper jaw allowing simultaneous rapid
maxillary expansion and skeletally borne maxillary
protraction. In the lower jaw the Bollard mini-plates by De
Clerck are usually inserted after eruption of the canines. To
allow earlier insertion of the mini-plate in the mandible, we
developed the Mentoplate (Figure 15)39). Since the Mentoplate
is inserted subapically to the lower incisors, it typically can be
used already at the age of 8-9 years. By means of the Hybrid
Hyrax in combination with a facemask or a Mentoplate forces
are applied to skeletal structures only with the goal to achieve
an optimum skeletal effect (Figure 15).
Conclusion
To summarize, the use of palatal TADs with abutments is
expanding the options in orthodontic and orthopedic treatment
significantly. Insertion and removal are minimally invasive
procedures: orthodontists can place the screws by themselves
and load them immediately. Usually, the screws can be
removed without anaesthesia. The anterior palate is our
preferred insertion region because of its superior bone quality
and relatively low rates of miniscrew instability and failure.
The attached mucosa has a better prognosis than other areas,
and there is no risk of tooth damage. In the mandible,
miniplates such as Bollard plates or the Mentoplate are
recommendable for orthopedic and orthodontic purposes.
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Figure 15 Skeletal borne early ClassⅢ treatment using the Hybrid Hyrax and the Mento-plate
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